Assertive community treatment as an alternative to incarceration for American pretrial detainees.

In the United States and elsewhere around the world, people with serious mental illness (SMI) are overrepresented in the criminal justice system. Clinical interventions to divert such individuals out of correctional settings, including Assertive Community Treatment (ACT), have been shown to reduce rates of criminal justice recidivism when modified to allow for the use of court sanctions to encourage treatment adherence. However, these interventions are noted to be underutilized as alternative to incarceration (ATI) programs. This paper summarizes the results of a retrospective cohort study conducted in a New York State forensic psychiatric hospital of 87 pretrial detainees admitted after being found incompetent to stand trial between January 2019 and January 2022. Of these, 49 patients were referred to an ACT team that served as an ATI program. The study outcomes noted that patients referred to this ACT team were 20% less likely to remain in pretrial detention than those that were not. Moreover, patients referred to the ACT program were also 34% more likely to be granted an ATI plea bargain in the community that did not involve serving a prison term. These results suggest that pretrial detainees with SMI are more likely to be granted an ATI program that offers more intensive treatment services such as ACT, due to the capability of such programs to also provide more intensive outreach and community supervision than traditional outpatient mental health service providers.

Using the HCR-20V3 to Differentiate Insanity Acquittees Based on Opinions of Readiness for Transfer.

After adjudication by the courts that an individual is not criminally responsible for the offense committed, forensic psychiatrists/psychologists are tasked with evaluating an acquittees' ongoing risk of violence. These findings determine whether an acquittee is retained in a forensic hospital or transferred to a civil psychiatric setting or into the community. Better understanding of risk factors that affect decisions to retain or release acquittees from secure forensic facilities would increase clarity in decision-making, assist evaluators in identifying who may be successful outside of secure settings, and potentially assist in the development and implementation of targeted treatments to address risk factors before and after transfer. The current study evaluated which risk factors of the Historical-Clinical-Risk Management 20, Version 3 differentiated acquittees whom clinicians opined to have a dangerous mental disorder and required retention from those whom clinicians opined to be ready for transfer to a less secure setting. Results indicated that the Clinical and Risk Management scales predicted opinions regarding readiness for transfer, even after accounting for acts of violence in the hospital. These findings suggest clinicians are attuned to relevant and current risk factors in evaluations, rather than disproportionately focused on historical factors. Implications for practice and future research are discussed.

Offense Characteristics of Incompetent to Stand Trial Defendants Charged With Violent Offenses.

The current study compared offender and offense characteristics of pretrial defendants found incompetent to stand trial (IST) against those described as general offenders by victims in the 2008 Bureau of Justice Statistics (BJS) survey and evaluated factors that differentiated IST defendants who allegedly used weapons from those who did not during the course of a violent offense. IST defendants were older and used "weapons" more frequently than those reported in the BJS survey; however, other characteristics, including use of firearms, did not differ. No demographic, clinical, or legal factors differentiated pretrial defendants who used weapons from those who did not. Overall, pretrial defendants were frequently diagnosed with a comorbid substance use disorder, and were homeless, unemployed, and had an extensive history of psychiatric hospitalizations and prior arrests at the time of their alleged offenses. Such results indicate that models for comprehensive discharge planning may have utility in addressing the unique needs of this subgroup of mentally disordered offenders. The findings also raise questions about the federal and state prohibition of gun rights to all IST defendants.

Factors associated with recommitment of NGRI acquittees to a forensic hospital.

The current archival study assesses risk factors associated with recommitment of 142 individuals adjudicated Not Guilty by Reason of Insanity (NGRI) from civil settings to a forensic hospital in New York State. Within 10 years of transfer from a forensic hospital, 40 (28.2%) were recommitted. Using survival analyses to account for the wide range in opportunity for recommitment, period of transfer (i.e., pre versus post the 1995 case of George L, which clarified factors related to assessments of dangerousness) and the Historical scale and specific items of the HCR-20 emerged as important risk factors for recommitment. Specifically, hazard of recommitment was 2.9 times higher for those with high Historical scores as compared to those with low scores. However, few individual risk factors were associated with recommitment. Prior supervision failure, negative attitude, problems with substance use, and absent or less serious major mental illness and relationship problems were informative in predicting recommitment over 10 and 3 year follow-up periods.

A cognitive, behaviorally based program for patients with persistent mental illness and a history of aggression, crime, or both: structure and correlates of completers of the program.

Standard psychiatric treatment programs have limited success in reducing recidivistic violent and criminal behavior in patients with persistent mental illness. A specialized, cognitive behavioral treatment program was developed for such a population. The purpose of this study was to identify factors that contribute to the patients' completing the program and to improve the selection criteria for program admission, so that those who participate are more likely to complete the program and be discharged. One hundred eighty-one patients with persistent mental illness with histories of aggression, crime, or both participated in a cognitive skills inpatient treatment program adapted for use with psychiatric patients. Ninety patients were able to complete the program and were discharged into the community. In comparison with the 91 who did not complete the program, those who did were less cognitively impaired and less impulsive. We present a new, intensive treatment program and define the predictors of successful completion of the program.

Neurocognitive correlates of the COMT Val(158)Met polymorphism in chronic schizophrenia.

BACKGROUND: Neurocognitive deficits are recognized as a cardinal feature of schizophrenia, but the determinants of these deficits remain unknown. Recent reports have suggested that a functional polymorphism, Val(158)Met in exon III of the catechol-O-methyltransferase gene, shares approximately 4% variance with performance on the Wisconsin Card Sorting Test. These findings led to suggestions that the catechol-O-methyltransferase polymorphism may exert its effects by modulating prefrontal dopamine function, but few other neurocognitive measures have been examined, leaving open questions about phenotypic specificity. METHODS: We examined the effects of the catechol-O-methyltransferase Val(158)Met polymorphism in 58 individuals with chronic schizophrenia who completed a battery of 15 neurocognitive tests, which were reduced to four reliable neurocognitive domain scores. We examined the effects of genotype on these four domains and on global neurocognitive ability. RESULTS: The Met allele was associated with better performance in the Processing Speed and Attention domain, but not with other domain scores measuring executive and visuoperceptual functions, declarative verbal learning and memory, simple motor ability, or global neurocognitive function. Genotype shared approximately 11% of variance with Processing Speed and Attention scores, and approximately 2% of variance with Wisconsin Card Sorting Test scores. CONCLUSIONS: The findings provide independent support for the hypothesis that the catechol-O-methyltransferase Val(158)Met polymorphism influences neurocognitive function in schizophrenia, and suggest that the functional effects may be expressed on measures of Processing Speed and Attention. This information may prompt reconsideration of the "prefrontal dopamine" hypothesis and invites examination of a broader range of effects in efforts to refine the neurocognitive phenotype that is most relevant to variation in catechol-O-methyltransferase expression.

Neurocognitive effects of clozapine, olanzapine, risperidone, and haloperidol in patients with chronic schizophrenia or schizoaffective disorder.

OBJECTIVE: Newer antipsychotic drugs have shown promise in ameliorating neurocognitive deficits in patients with schizophrenia, but few studies have compared newer antipsychotic drugs with both clozapine and conventional agents, particularly in patients who have had suboptimal response to prior treatments. METHOD: The authors examined the effects of clozapine, olanzapine, risperidone, and haloperidol on 16 measures of neurocognitive functioning in a double-blind, 14-week trial involving 101 patients. A global score was computed along with scores in four neurocognitive domains: memory, attention, motor function, and general executive and perceptual organization. RESULTS: Global neurocognitive function improved with olanzapine and risperidone treatment, and these improvements were superior to those seen with haloperidol. Patients treated with olanzapine exhibited improvement in the general and attention domains but not more than that observed with other treatments. Patients treated with risperidone exhibited improvement in memory that was superior to that of both clozapine and haloperidol. Clozapine yielded improvement in motor function but not more than in other groups. Average effect sizes for change were in the small to medium range. More than half of the patients treated with olanzapine and risperidone experienced "clinically significant" improvement (changes in score of at least one-half standard deviation relative to baseline). These findings did not appear to be mediated by changes in symptoms, side effects, or blood levels of medications. CONCLUSIONS: Patients with a history of suboptimal response to conventional treatments may show cognitive benefits from newer antipsychotic drugs, and there may be differences between atypical antipsychotic drugs in their patterns of cognitive effects.